[Aetiology and management of iatrogenic injury of the ureter: a review]

Ureterocalicostomy for complex upper ureteral stricture: a narrative review of the current literature

Upper ureteral stricture is a relatively rare but increasingly encountered condition in clinical practice. While simple stricture can often be addressed through endoluminal treatment or surgical reconstruction, complex upper ureteral stricture poses challenges, particularly in patients with ureteropelvic junction obstruction (UPJO) or perirenal pelvic fibrosis and scarring resulting from previous surgeries. These cases present difficulties for traditional endoluminal and ureteral reconstruction treatments, posing a significant problem for many clinical surgeons. Our study involved a thorough search and comprehensive analysis of the existing literature on Ureterocalicostomy (UC). The literature indicates that UC is a safe and effective treatment for ureteral stenosis. By resecting the renal lower pole parenchyma, it is possible to achieve mucosal anastomosis between the calyceal and ureteral mucosa, leading to the restoration of normal urinary excretion. This technique has emerged as an alternative for treating complex upper ureteral strictures. However, there is a lack of direct comparative studies between open surgery and minimally invasive surgery. Our findings revealed a scarcity of relevant review documents, with most being case reports or retrospective studies conducted in single centers with small sample sizes. Therefore, it is crucial to conduct large-scale, multicenter prospective studies and long-term follow-up to validate the long-term efficacy of UC. This article reviews the development history of UC and focuses on a comprehensive discussion of its indications, surgical techniques, and complications.

Iatrogenic ureteral injury: What should the digestive surgeon know?

PURPOSE OF THE STUDY

Iatrogenic ureteral injury (IUI) is a rare but formidable complication of any abdominal or pelvic surgery. The aim of this study was to describe the epidemiology of IUI in colorectal surgery in the Basse-Normandie region over the period 2004-2022, as well as to review the literature on the management of this complication.

MATERIALS AND METHODS

This multicenter retrospective analysis of clinical data (medical records and operative reports) concerned 22 patients (13 men and 9 women) who suffered an IUI during colorectal surgery between 2004 and 2022. Ureteral resections for oncological purposes and endoluminal instrumental injuries (post-ureteroscopy) were excluded from the study. We also carried out a review of the literature concerning the incidence of IUI in colorectal surgery.

RESULTS

The incidence of IUI was 0.27% over the study period (22 ureteral injuries out of 8129 colorectal procedures). Colorectal cancer and sigmoid diverticulitis were the dominant surgical indications (85% of cases). Proctectomy and left colectomy were the most performed resection procedures (75% of cases). Surgery was scheduled in 68% of cases. The approach was open laparotomy in 59% and laparoscopy in 41% of cases. The IUI involved the left ureter in 63% of cases and the pelvic ureter in 77% of cases. Conservative endoscopic treatment by insertion of a double-J catheter stent had a success rate of 87.5%. Surgical repairs consisting of re-implantation techniques and uretero-ureteral anastomosis had a success rate of 75%. The nephrectomy rate was 13.6% (3/22) and the mortality rate 9% (2/22). A literature review identified sixteen studies, where the incidence of IUI varied from 0.1 to 4.5%.

FINDINGS

IUI occurring during colorectal surgery is a rare occurrence but remain a formidable complication. No means of prevention has proven its effectiveness to date, but guidance devices using illuminated ureteral catheters or dyes seem to constitute a promising approach. Injuries to the left pelvic ureter are the most common, and the majority can be treated endoscopically if diagnosed early.

Management strategies and root causes of missed iatrogenic intraoperative ureteral injuries with delayed diagnosis: a retrospective cohort study of 40 cases

BACKGROUND

Intraoperative iatrogenic ureteral injuries represent rare technical surgical complications with the potential for adverse patient outcomes, particularly when the diagnosis is delayed. Ideally, these technical complications are recognized and repaired intraoperatively. This study was designed to investigate the root causes and outcomes of missed intraoperative ureteral injuries at a tertiary urology referral centre in Tunisia.

METHODS

This is a retrospective cohort study in a tertiary urology referral centre in Tunis from January 1^st, 2015, to December 31^st, 2020, including all patients with iatrogenic ureteral injury, not diagnosed intraoperatively. The factors associated with the success of endoscopic treatment and those associated with the unfavourable evolution were investigated.

RESULTS

A total of 40 iatrogenic ureteral injuries were included. Gynaecological surgery was responsible for 85% of ureteral injuries, mainly during hysterectomies (55%). The symptoms were dominated by low back pain (37.5%) and pyelonephritis (25%). Endoscopic treatment was attempted in 22 cases, it was sufficient in 12 cases. Ureteral injury required surgical treatment in 24 cases, and ureteroneocystostomy was performed in 16 cases. Nephrectomy was performed in eight cases, representing 20% of injuries, including three cases as the first treatment for late-diagnosed cases with a destroyed kidney. In the analytical study, endoscopic treatment was sufficient in 50% in case of ureteral fistula versus 27% in case of ureteral stenosis (p = 0.04). Nephrectomy was performed in 10% of cases when ureteral injury was diagnosed within the first month postoperatively compared to 60% of cases when this delay exceeded one month (p = 0.004).

CONCLUSION

Iatrogenic ureteral injuries discovered postoperatively are mostly secondary to gynaecologic surgery. Although endoscopic treatment is usually performed as a first treatment, a more aggressive surgical is often necessary, with a nephrectomy rate of 20%.

Bioengineering solutions for Ureteric disorders: Clinical need, challenges and opportunities

Objectives

To summarise the causes of ureteric damage and the current standard of care, discussing the risks and benefits of available therapeutic options. We then focus on the current and future solutions that can be provided by ureteric bioengineering and provide a description of the ideal characteristics of a bioengineered product.

Methods

We performed a literature search in February 2021 in: Google Scholar, Medline, and Web of Science. Three searches were conducted, investigating: (a) the epidemiology of ureteric pathology, (b) the current standard of care, and (c) the state of the art in ureteric bioengineering.

Results

The most‐common causes of ureteric damage are iatrogenic injury and external trauma. Current approaches to treatment include stent placement or surgical reconstruction. Reconstruction can be done using either urological tissue or segments of the gastrointestinal tract. Limitations include scarring, strictures, and infections. Several bioengineered alternatives have been explored in animal studies, with variations in the choice of scaffold material, cellular seeding populations, and pre‐implantation processing. Natural grafts and hybrid material appear to be associated with superior outcomes. Furthermore, seeding of the scaffold material with stem cells or differentiated urothelial cells allows for better function compared to acellular scaffolds. Some studies have attempted to pre‐implant the graft in the omentum prior to reconstruction, but this has yet to prove any definitive benefits.

Conclusion

There is an unmet clinical need for safer and more effective treatment for ureteric injuries. Urological bioengineering is a promising solution in preclinical studies. However, substantial scientific, logistic, and economic challenges must be addressed to harness its transformative potential in improving outcomes.

Iatrogenic Ureteral Injuries Associated with Gynecological and Surgical Procedures: Our Experience About 18 Cases and Literature Review

Aim

To describe the epidemiological aspects, etiology and outcome of iatrogenic ureteral injury repair at the urology division of Souro Teaching Hospital of Bobo Dioulasso (Burkina-Faso).

Patients and Methods

This was a retrospective descriptive study of consecutive patients with iatrogenic ureteric injuries who were referred and managed in the urology division of Souro Sanou Teaching Hospital (Bobo-Dioulasso) from January 2012 to December 2017. Variables studied were age, the time at the diagnosis, the causative event, the method of repair, and the outcome of the management.

Results

The mean age was 37.72±3.5 years coming from the rural population in most cases. The mean time at the diagnosis was 15 days. The injuries were due to gynecologic surgeries with hysterectomy (66%) and caesarian section (33%). Ureteric reimplantation with anti-reflux system was performed in seventeen patients. The rate of treatment success was 94% and the postoperative course was uneventful for all the patients.

Conclusion

Iatrogenic ureteric lesions at the department of urology of Sanou Sourou teaching hospital of Bobo Dioulasso were mainly caused by gynecologic and obstetric surgeries like hysterectomy and caesarian section.

[Endoscopic management of postoperative ureteral wound. Retrospective unicentric study from October 2003 to June 2014]

BACKGROUND

Ureteral wounds are rare with an incidence of 0.5 to 1% of pelvic surgeries. Their supports and their prognosis remain dependant of the period of support and the level of ureteral lesion. The importance of early treatment reduces morbidity and improves patient prognosis.

METHODS

A retrospective study from October 2003 to June 2014 was performed in a university hospital using a systematic chart review of patients' urology, digestive surgery, vascular surgery and gynecology.

RESULTS

Forty-six wounds were found in 43 patients. The majority of the ureteral wound was found at the pelvic ureter, i.e. 69.6% of the study population (n=32). The main cause was gynecological surgery (n=25). In the simple wound group, endoscopic treatment was effective in nearly 90% of cases (n=6). In the other two groups, the efficacy was only 30% and imposed a surgical treatment as second-line.

CONCLUSION

The management is based primarily on early detection or intraoperative, and on a correct initial knowledge of the location and size of the lesion. Endoscopic treatment can in most cases treated with a simple and minimally invasive operation an ureteral wound with nearly 90% success rate. In more complex wounds, endoscopy remains a step in the management with about 30% success rate in our study.

LEVEL OF EVIDENCE

5.

[Functional outcomes obtained after vesicoureteral reimplantation surgery in adults: A review]

OBJECTIVES

Vesico-ureteral reimplantations (VUR) for adults are complex procedures, often practicing for distal ureteral lesions. Our goal was to synthesis the main indications for VUR, different techniques and their functional outcomes.

MATERIAL AND METHODS

A literature review in English by Medline, Embase and Google scholar was performed using the following keywords: ureter; laparoscopy; robotics, reimplantation; surgery; obstruction; morbidity; complications; psoas hitch; Boari flap; ureteroneocystostomy.

RESULTS

In more than half of the cases, aetiology was a iatrogenic ureteral lesion. When the ureteral defect was less than 2 cm, direct or non-refluxing VUR was the technique of choice. If defect was superior than 2 cm the Boari flap or vesicopsoas hitch were preferred. Several surgical approaches were feasible: open, laparoscopic only, robot assisted laparoscopic. Estimated blood loss, pain and mean hospital stay seemed better with conventional or robotic coelioscopy. Nevertheless, complications, pre-/post-operative renal function and mean operative time seemed similar. The most frequent major complication was the anastomotic urine leakage.

CONCLUSIONS

The VUR techniques are well codified now even if it's a rare procedure. Functional outcomes are satisfied according to literature and morbidity is more and more decreasing but the level of evidence of the studies is low.

Current epidemiology of genitourinary trauma

This article reviews recent publications evaluating the current epidemiology of urologic trauma. The authors briefly explain databases that have been recently used to study this patient population and then discuss each genitourinary organ individually, utilizing the most relevant and up-to-date information published for each one. The conclusion of the article briefly discusses possible future research and development areas pertaining to the topic.